Provider Demographics
NPI:1588770606
Name:BALD MOUNTAIN MEDICAL PHARMACY
Entity type:Organization
Organization Name:BALD MOUNTAIN MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTRAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-814-9814
Mailing Address - Street 1:1375 S LAPEER RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1421
Mailing Address - Country:US
Mailing Address - Phone:248-814-9814
Mailing Address - Fax:248-814-9818
Practice Address - Street 1:1375 S LAPEER RD STE 103
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1421
Practice Address - Country:US
Practice Address - Phone:248-814-9814
Practice Address - Fax:248-814-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007701333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2364862OtherNCPDP
MI2364862OtherNCPDP